Management Of Status Epilepticus Research Articles

Early Neurologic Recovery, Practice Pattern Variation, and the Risk of Endotracheal Intubation Following Established Status Epilepticus.

To quantify the association between early neurologic recovery, practice pattern variation, and endotracheal intubation during established status epilepticus, we performed a secondary analysis within the cohort of patients enrolled in the Established Status Epilepticus Treatment Trial (ESETT). We evaluated factors associated with the endpoint of endotracheal intubation occurring within 120 minutes of ESETT study drug initiation. We defined a blocked, stepwise multivariate regression, examining 4 phases during status epilepticus management: (1) baseline characteristics, (2) acute treatment, (3) 20-minute neurologic recovery, and (4) 60-minute recovery, including seizure cessation and improving responsiveness. Of 478 patients, 117 (24.5%) were intubated within 120 minutes. Among high-enrolling sites, intubation rates ranged from 4% to 32% at pediatric sites and 19% to 39% at adult sites. Baseline characteristics, including seizure precipitant, benzodiazepine dosing, and admission vital signs, provided limited discrimination for predicting intubation (area under the curve [AUC] 0.63). However, treatment at sites with an intubation rate in the highest (vs lowest) quartile strongly predicted endotracheal intubation independently of other treatment variables (adjusted odds ratio [aOR] 8.12, 95% confidence interval [CI] 3.08-21.4, model AUC 0.70). Site-specific variation was the factor most strongly associated with endotracheal intubation after adjustment for 20-minute (aOR 23.4, 95% CI 6.99-78.3, model AUC 0.88) and 60-minute (aOR 14.7, 95% CI 3.20-67.5, model AUC 0.98) neurologic recovery. Endotracheal intubation after established status epilepticus is strongly associated with site-specific practice pattern variation, independently of baseline characteristics, and early neurologic recovery and should not alone serve as a clinical trial endpoint in established status epilepticus. ClinicalTrials.gov Identifier: NCT01960075.

Managing Status Epilepticus in a Child with Dravet Syndrome: How Difficult It Could Be?

AbstractPreviously known as severe myoclonic epilepsy of infancy, Dravet syndrome is characterized by febrile or afebrile prolonged hemiconvulsive seizures or generalized status epilepticus in an infant with previously normal development. Immediate management of status epilepticus is critical in these patients. Early control of status epilepticus prevents further brain damage; however, there is no consensus regarding the management of status epilepticus in children with Dravet syndrome, as many conventional antiseizure medications that are recommended in the management of status epilepticus worsen the seizures in these patients. A 2.5-year-old girl child patient was referred due to status epilepticus which was refractory to antiseizure medications. Sodium valproate, nitrazepam, ketogenic diet, intravenous phenytoin, and midazolam continuous infusion were administered. After controlling status epilepticus, the probable diagnosis of Dravet syndrome was proposed and confirmed by a mutation in SCN1A. As previously stated in numerous case reports, phenytoin worsens seizures in patients with Dravet syndrome. Therefore, it seems logical that in every infant with status epilepticus and probable Dravet syndrome, the practicing physician considers administering intravenous valproate or even midazolam continuous infusion instead of intravenous phenytoin.

Assessment of benzodiazepine dosing strategies for the management of status epilepticus in the emergency department.

Although guidelines recommend specific benzodiazepine doses for the treatment of generalized convulsive status epilepticus (GCSE), underdosing appears to be common. The purpose of this investigation was to assess benzodiazepine dosing strategies for the initial management of GCSE in patients presenting to the Emergency Department (ED). This was a retrospective review of adult patients who received benzodiazepines in the ED for treatment of GCSE. Characteristics of those achieving seizure cessation following initial benzodiazepine therapy were assessed. 222 patients presented to the ED and received 403 doses of benzodiazepines, of which 1.5% conformed with recommendations. First-line therapy was successful in 86.8% of patients with an average dose of 1.6mg (0.02mg/kg). No difference in dosing was noted between those experiencing early cessation and those that did not (p=0.132). Patients experiencing early cessation were significantly less likely to receive further doses, be intubated, or be admitted to the intensive care unit (ICU) or hospital (p<0.05 for all comparisons). Those that received early antiepileptic drug therapy were significantly less likely to receive additional benzodiazepine doses, be intubated, or be admitted to the ICU or hospital (p<0.05 for all comparisons). According to guideline recommendations, there was consistent underdosing of benzodiazepines noted in both prehospital and ED settings. Early seizure cessation and the early receipt of an antiepileptic drug were found to be associated with multiple significant clinical outcomes. Future investigations should explore optimal dosing strategies for benzodiazepines as well as the impact of early antiepileptic drug administration.

Update on the management of status epilepticus.

Randomized controlled trials investigating the initial pharmacological treatment of status epilepticus have been recently published. Furthermore, status epilepticus arising in comatose survivors after cardiac arrest has received increasing attention in the last years. This review offers an updated assessment of status epilepticus treatment in these different scenarios. Initial benzodiazepines underdosing is common and correlates with development of status epilepticus refractoriness. The recently published ESETT trial provides high-level evidence regarding the equivalence of fosphenytoin, valproate, and levetiracetam as a second-line option. Myoclonus or epileptiform transients on electroencephalography occur in up to 1/3 of patients surviving a cardiac arrest. Contrary to previous assumptions regarding an almost invariable association with death, at least 1/10 of them may awaken with reasonably good prognosis, if treated. Multimodal prognostication including clinical examination, EEG, somatosensory evoked potentials, biochemical markers, and neuroimaging help identifying patients with a chance to recover consciousness, in whom a trial with antimyoclonic compounds and at times general anesthetics is indicated. There is a continuous, albeit relatively slow progress in knowledge regarding different aspect of status epilepticus; recent findings refine some treatment strategies and help improving patients' outcomes. Further high-quality studies are clearly needed to further improve the management of these patients, especially those with severe, refractory status epilepticus forms.

Recognition and treatment of status epilepticus in the prehospital setting

PurposeWe performed this retrospective data bank analysis to evaluate the management of status epilepticus (SE) in the prehospital setting and the possible association of treatment delay or insufficient treatment approach with outcome. MethodWe evaluated all treatment episodes of a prehospital SE according to our hospital record system between January 1st 2014 and December 31st 2018. Classification according to the ILAE classification of 2015, Status Epilepticus Severity Score (STESS), Charlson Comorbidity Index (CCI) at admission and the Modified Rankin Scale (mRS) at discharge or in hospital death were recorded or calculated. Statistical analysis was performed with the Mann-Withney-U test, the Chi-Square test and corrections of Yates and Bonferroni-Holmes where appropriate. ResultsThere were 331 treatment episodes in 282 patients with a fatality rate of 7.6 %. Median age at treatment was 72 years. Patients who died were significantly older and had a higher STESS and CCI than patients who survived. SE was recognised in the prehospital setting in only 56.8 % of treatment episodes. Patients in treatment episodes with recognized SE were significantly younger than the others. Status epilepticus was more often recognized, when epilepsy was known. Overall in 48 % of treatment episodes with another SE type than generalized convulsive SE the diagnosis was missed. CCI was significantly higher in the episodes without recognized SE. Patients were more often discharged from hospital with a new deficit, when the SE was not recognized in the prehospital setting. In treatment episodes with initiation of a benzodiazepine (BZD) the patients were more likely to be discharged without a new deficit than others. After excluding cases with insufficient documentation of treatment steps 273 treatment episodes remained. In 178 of these treatment episodes epilepsy was known before, but in only 11.2 % of them a rescue medication was given by bystanders. In only 6.7 % of treatment episodes of SE in patients with known epilepsy a BZD was given in an appropriate way by bystanders. In nearly all treatment episodes with lorazepam (88.9 %) or midazolam (97.8 %) the dosage was below the recommended level. ConclusionsMissing the SE in the prehospital setting was frequent and associated with a higher risk of developing a new neurological deficit. Treatment with BZD was associated with a lower risk of developing a new neurological deficit, but was underdosed in the vast majority of situations.

Statewide Emergency Medical Services Protocols for Status Epilepticus Management.

Although seizures are common in prehospital settings, standardized emergency medical services (EMS) treatment algorithms do not exist nationally. We examined nationwide variability in status epilepticus treatment by analyzing 33 publicly available statewide EMS protocols. All adult protocols recommend intravenous benzodiazepines (midazolam, n = 33; lorazepam, n = 23; diazepam, n = 24), 30 recommend intramuscular benzodiazepines (midazolam, n = 30; lorazepam, n = 8; diazepam, n = 3), and 27 recommend intranasal benzodiazepines (midazolam, n = 27; lorazepam, n = 3); pediatric protocols also frequently recommend rectal diazepam (n = 14). Recommended dosages vary widely, and first- and second-line agents are designated in only 18 and 2 states, respectively. Given this degree of variability, standardized national EMS guidelines are needed. ANN NEUROL 2021;89:604-609.

Updates on classification and management of status epilepticus

Updates on classification and management of status epilepticus

Continuous EEG use and status epilepticus treatment in Australasia: a practice survey of Australian and New Zealand epileptologists

ObjectiveContinuous electroencephalography (cEEG) is increasingly used to detect non-convulsive seizures in critically ill patients but is not widely practised in Australasia. Use of cEEG is also influencing the management of...

A comparison of intravenous midazolam and diazepam in management of status epilepticus in children.

To compare the efficacy of intravenous midazolam and diazepam in the management of status epilepticus seizures in children. The comparative study was conducted in the paediatric neurological emergency unit of The Children's Hospital and the Institute of Child Health, Multan, Pakistan, from December 15, 2018, to May 14, 2019, and comprised paediatric patients of status epilepticus seizures which were divided into Diazepam and Midazolam groups. Data was analysed using Graph-Pad Prism 5. Of the 164 patients, 82(50%) were in each of the two groups. There was no significant difference between the groups in terms of weight, age, residence area of patients and mean duration of seizures (p>0.05). Status epilepticus seizures subsided after intravenous midazolam administration in 77(93.90%) cases, while success in the diazepam group 64(78.05%) (p<0.05). Mean time taken by midazolam to halt seizures was significantly shorter than diazepam (p<0.05) and less cases of treatment failure were observed with intravenous midazolam (p<0.05). Somnolence was observed after diazepam administration in 47(57.3%) cases (p=0.0001). Intravenous midazolam was found to be superior in efficacy than intravenous diazepam in controlling status epilepticus seizures.

Principles of Pharmacotherapy of Seizures and Status Epilepticus.

Status epilepticus is a neurological emergency with an outcome that is highly associated with the initial pharmacotherapy management that must be administered in a timely fashion. Beyond first-line therapy of status epilepticus, treatment is not guided by robust evidence. Optimal pharmacotherapy selection for individual patients is essential in the management of seizures and status epilepticus with careful evaluation of pharmacokinetic and pharmacodynamic factors. With the addition of newer antiseizure agents to the market, understanding their role in the management of status epilepticus is critical. Etiology-guided therapy should be considered in certain patients with drug-induced seizures, alcohol withdrawal, or autoimmune encephalitis. Some patient populations warrant special consideration, such as pediatric, pregnant, elderly, and the critically ill. Seizure prophylaxis is indicated in select patients with acute neurological injury and should be limited to the acute postinjury period.

Status Epilepticus: Work-Up and Management in Adults.

Status epilepticus is one of the most common neurological emergencies and is likely to have increasing prevalence in coming years given an aging "baby boomer" population in the United States. Because status epilepticus is associated with significant morbidity and mortality, identification and treatment are paramount. Care should be taken to exclude nonorganic mimics and infectious and metabolic causes. Status epilepticus can be classified into stages with associated recommendations for escalation in therapy, increasing from push-dose benzodiazepines to continuous anesthetic infusions and other nontraditional therapies. Concurrent electroencephalogram monitoring helps to identify, localize, and assess resolution of ictal patterns alongside antiseizure drug administration. A protocol is proposed for the management of status epilepticus in a step-wise fashion.

Ketogenic Diet Therapies for Seizures and Status Epilepticus.

Ketogenic diet therapies are high-fat, low-carbohydrate diets designed to mimic a fasting state. Although initially developed nearly one century ago for seizure management, most clinical trials for the management of drug-resistant epilepsy in children as well as adults have been conducted over the last 3 decades. Moreover, ketogenic diets offer promising new adjunctive strategies in the critical care setting for the resolution of acute status epilepticus when traditional antiseizure drugs and anesthetic agents fail. Here, we review the history of ketogenic diet development, the clinical evidence supporting its use for the treatment of drug-resistant epilepsy in children and adults, and the early evidence supporting ketogenic diet feasibility, safety, and potential efficacy in the management of status epilepticus.

53. PRACTICE MAKES PERFECT: USING REPETITIVE, SMALL-CHANGE SIMULATION FOR EMERGENT PEDIATRIC SCENARIOS

Background Simulation is a cornerstone of residency training across disciplines. Studies show repeated exposure to the same case scenario may improve medical decision making, but little is known about how this affects the learning experience. Methods All pediatric residents participate in simulation exercises both in situ and at our state-of-the-art simulation center. Each scenario includes a nurse and parent who are simulated actors, as well as a child mannequin. Residents at all phases of training work in groups of 3-4. Two categories of simulation scenarios were created. The first reviewed management of status epilepticus - one patient with known epilepsy and the second a hypoglycemic child with an insulin overdose. The second category was management of tachycardia - one patient with sepsis and the second with supraventricular tachycardia. The patient's age, weight, overall appearance, and vital signs were identical in each category. Subtle differences in history and physical exam were present, which residents had to elucidate without prompting. Each group performed two different cases with the same chief complaint. Groups were assessed using the Simulation Team Assessment Tool (STAT), a validated tool published in Resuscitation. Results Seven groups of residents participated from July to December 2019 for 14 total cases. The average STAT score for resident teams participating in the first tachycardia case was 13.75/16 (0.86), while the average in the second scenario was 18/18 (1.00). The average STAT score for teams participating in the first seizure case was 12.3/16 (0.77), while the average in the second case was 15.66/18 (0.87). Average resident satisfaction scores were equal across first and second scenarios at 4.85/5. Conclusions Repetitive simulation using subtle differences in history and physical exam allows for an opportunity to practice important life-saving skills for pediatric residents, while also allowing for some variation and avoidance of repetition bias. This format can easily be modified and applied towards other emergent pediatric situations based on learner needs.

Pick Your Poison but Pick It Wisely: Choosing a Second-Line Medication for the Management of Status Epilepticus.

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Evaluation of adherence to pediatric status epilepticus management guidelines in Saudi Arabia.

Objectives:To assess compliance with the 2017 Saudi pediatric status epilepticus management guidelines and to printout the main obstacle for adherence to the guidelines.Methods:A Cross sectional study conducted in September 2019, using electronic survey. The survey sent to all the Pediatric Emergency physicians practicing in Kingdom of Saudi Arabia (KSA) through emails and WhatsApp and the questionnaire based on clinical scenario written in English language.Results:One hundred and three (70%) of 147 physicians working in KSA and covering pediatric emergency departments responded to the survey. Only 20% of the physicians reported full compliance to all 4 guideline components; 57% reported that they were not aware of the published guidelines.Conclusion:Pediatric emergency physicians reported poor compliance to the 2017 published guidelines for the treatment of children with convulsive status epilepticus in KSA.

Use of a simulation-based mastery learning curriculum for neurology residents to improve the identification and management of status epilepticus

BackgroundAppropriate and timely treatment of status epilepticus (SE) decreases morbidity and mortality. Therefore, skill-based training in the identification and management of SE is crucial for clinicians. ObjectiveThe objective of the study was to develop and evaluate the impact of a simulation-based mastery learning (SBML) curriculum to train neurology residents on the identification and management of SE. MethodsWe used pretest–posttest design with a retention test on SE skills for this study. Neurology residents in the second postgraduate year (PGY-2) were eligible to participate in the SE SBML curriculum. Learners completed a baseline-simulated SE skills assessment (pretest) using a 26-item dichotomous skills checklist. Next, they participated in a didactic session about the identification and management of SE, followed by deliberate skills practice. Subsequently, participants completed another skills assessment (posttest) using the same 26-item checklist. All participants were required to meet or exceed a minimum passing standard (MPS) determined by a panel of 14 SE experts using the Mastery Angoff standard setting method. After meeting the MPS at posttest, participants were reassessed during an unannounced in situ simulation session on the medical wards. We compared pretest with posttest simulated SE skills performance and posttest with reassessment in situ performance. ResultsThe MPS was set at 88% (23/26) checklist items correct. Sixteen neurology residents participated in the intervention. Participant performance improved from a median of 44.23% (Interquartile range (IQR): 34.62–55.77) at pretest to 94.23% (IQR: 92.13–100) at the posttest after SBML (p < .001). There was no significant difference in scores between the posttest and in situ test up to 8 months later (94.23%; IQR: 92.31–100 vs. 92.31%; IQR: 88.46–96.15; p = .13). ConclusionsOur SBML curriculum significantly improved residents' SE identification and management skills that were largely retained during an unannounced simulated encounter in the hospital setting.

Simulation-based Mastery Learning Improves Residents’ Identification and Management of Status Epilepticus (819)

Simulation-based Mastery Learning Improves Residents’ Identification and Management of Status Epilepticus (819)

From international guidelines to real-world practice consensus on investigations and management of status epilepticus in adults: A modified Delphi approach

ObjectiveTo establish a consensus which is practical and ready-to-use on investigations (ISE) and for management of status epilepticus (MSE) in adults using a modified Delphi approach. Patients and methodsA 4-round modified Delphi approach was used. First and second rounds were conducted using Google® survey with structured statements and 6-point Likert scale response. Threshold agreement was set to ≥80%. Third round was a face-to-face meeting aimed to facilitate the development of approach algorithms for ISE and MSE. Fourth round was a final review asking participants to rate the algorithms post completion. ResultsThe panel consisted of 8 board-certified epileptologists along with 6 neurologists from main regional hospitals across Thailand. Thirty-seven statements for ISE and 68 statements for MSE were used for the Round I survey, 17/37 (45.9%) and 49/68 (72.1%) reached threshold agreement (≥80%). The average absolute-agreement intraclass correlation coefficients for ISE and MSE were 0.82 (95% CI 0.71, 0.89) and 0.81 (95% CI 0.73, 0.87), respectively; indicating good extent of consensus among participants. Upon Round II, further 10/18 (55.6%) for ISE and 10/19 (52.6%) for MSE reached agreement. In Round III, face-to-face point-by-point discussion was performed to generate approach algorithms. All (100%) provided positive responses with the algorithms post completion in Round IV. ConclusionA practical and ready-to-use consensus using modified Delphi approach on ISE and MSE was developed in a Thai regional hospital context. In real practice, this approach is more suitable and feasible for a localized setting when compared with totally adopting international guidelines.

Emergency management of status epilepticus in a high-fidelity simulation: A prospective study.

To quantify the quality of physicians' emergency first response to status epilepticus (SE) and to identify risk factors for nonadherence to treatment guidelines in a standardized simulated scenario. In this prospective trial, 58 physicians (of different background) of the University Hospital Basel, a Swiss academic medical care center, were confronted with a simulated SE. Primary outcomes were time to (1) airway protection, (2) supplementary oxygen, and (3) administration of antiseizure drugs (ASDs). All physicians recognized ongoing seizures. Airways were checked by 54% and protected by 16% within a median of 3.9 minutes. Supplementary oxygen was administered by 76% with a median of 2.8 minutes. First-line ASDs were administered by 98% (benzodiazepines 97% within a median of 2.9 minutes), and second-line ASDs by 57% within 8.1 minutes. Regarding secondary outcomes, the median time to monitor blood pressure and heart rate was 1.8 (interquartile range [IQR] 1.3-2.6) and 2.0 (IQR 1.4-2.7) minutes, respectively. Neurologic affiliation of physicians was associated with inadequate assessments of vital signs (odds ratio [OR] = 0.2; 95% CI 0.04-0.93) and most frequent administration of second-line ASDs (OR = 5.0; 95% CI 1.01-25.3). Knowing treatment guidelines and subjective certainty regarding SE diagnosis were associated with frequent administration of second-line ASDs (OR = 10.4; 95% CI 1.2-88.1). Nonadherence to SE treatment guidelines is frequent. The lack of airway assessment and protection in the simulated clinical scenario of SE may increase mortality and promote treatment refractoriness related to aspiration pneumonia. Guideline-based clinical training is urgently needed to increase the quality of SE management. ISRCTN registry (ID ISRCTN60369617; www.isrctn.com/ISRCTN60369617).

Comparison of intranasal versus intravenous midazolam for management of status epilepticus in dogs: A multi-center randomized parallel group clinical study.

BackgroundThe intranasal (IN) route for rapid drug administration in patients with brain disorders, including status epilepticus, has been investigated. Status epilepticus is an emergency, and the IN route offers a valuable alternative to other routes, especially when these fail.ObjectivesTo compare IN versus IV midazolam (MDZ) at the same dosage (0.2 mg/kg) for controlling status epilepticus in dogs.AnimalsClient‐owned dogs (n = 44) with idiopathic epilepsy, structural epilepsy, or epilepsy of unknown origin manifesting as status epilepticus.MethodsRandomized parallel group clinical trial. Patients were randomly allocated to the IN‐MDZ (n = 21) or IV‐MDZ (n = 23) group. Number of successfully treated cases (defined as seizure cessation within 5 minutes and lasting for ≥10 minutes), seizure cessation time, and adverse effects were recorded. Comparisons were performed using the Fisher's exact and Wilcoxon rank sum tests with statistical significance set at α < .05.ResultsIN‐MDZ and IV‐MDZ successfully stopped status epilepticus in 76% and 61% of cases, respectively (P = .34). The median seizure cessation time was 33 and 64 seconds for IN‐MDZ and IV‐MDZ, respectively (P = .63). When the time to place an IV catheter was taken into account, IN‐MDZ (100 seconds) was superior (P = .04) to IV‐MDZ (270 seconds). Sedation and ataxia were seen in 88% and 79% of the dogs treated with IN‐MDZ and IV‐MDZ, respectively.Conclusions and Clinical ImportanceBoth routes are quick, safe, and effective for controlling status epilepticus. However, the IN route demonstrated superiority when the time needed to place an IV catheter was taken into account.